oghfa 1_hp_06_vis_error management 1 error management oghfa 1_hp_06_vis_error management 1

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 1

Error Error

ManagementManagement

Error Error

ManagementManagement

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 1

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 2

Normal operations:• threats and errors• deviations• failures and successes

Accidents

Serious incidents

Minor incidents

Frequency of event, Quantity of data

Sev

erit

y of

eve

nt

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 3

Frequency of event, Quantity of data

Sev

erit

y of

eve

nt

Normal operations:• threats and errors• deviations• failures and successes

Accidents

Serious incidents

Minor incidents

Normal operations:• threats and errors• deviations• failures and successes

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 4

LOSA (Line Operations Safety Audit) results:

More than 70% of flights had at least one error or violation

About 30% of errors/violations were mismanaged or consequential

Leading to “undesired aircraft state” or another error/violation

Courtesy of University of Texas. Based on 3309 flights.

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 5

This presentation is about coping with

errors in normal operations, typically detected

with flight operations monitoring tools,

It is not about incidents, usually subject to a detailed investigation.

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 6

1. Why do we sometimes fail?

2. Consequences on flight safety

3. Managing errors and violations

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 7

1. Why do we sometimes fail?

2. Consequences on flight safety

3. Managing errors and violations

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 8

© Ismo Aaltonen

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 9

Intention to achieve somethingGood planAction “on autopilot”Unintended deviation from plan

Several error mechanisms, for example:“Strong but wrong” habits

Inaccuracies

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 10

The climb is getting bumpy…

Radar was off!

Predictive windshear had been set to “auto”

Radar remained off

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 11

Intention to achieve something

Good plan

Something is skipped, omitted

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 12

Mistake

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 13

Intention to achieve something

The solution is…Deficient

Wrong

Dangerous

Clumsy

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 14

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 15

Deliberate violation of a rule, procedure, policy or norm

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 16

Completely newCompletely new

RoutineRoutine

Mistakes(capacity overflow)

Slips & Lapses

Mistakes(incorrect solutions)

Exceptionalviolations

Routineviolations

Optimizingviolations

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 17

1. Why do we sometimes fail?

2. Consequences on flight safety

3. Managing errors and violations

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 18

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 19

There is a very loose coupling between an error and negative consequences

Other factors shape the outcome

Especially true in aviation

Nevertheless…

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 20

Flaps not set for takeoff (lapse)Aircraft type and performance?

Actual takeoff weight?

Runway length?

Obstructions ahead?

Takeoff configuration warning?

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 21

1. Why do we sometimes fail?

2. Consequences on flight safety

3. Managing errors and violations

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 22

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 23

ERROR PREVENTION

ERROR MANAGEMENT

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 24

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 25

Error ReductionMinimizing the likelihood of error

Minimizing the consequences of error

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 26

Error DetectionFacilitate easy and rapid detection of errors

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 27

Error Management Strategies

Error RecoveryMake it easy to rapidly recover to a safe state

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 28

Error ToleranceBuild the system to

tolerate errors

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 29

Error PreventionWhere reasonable and where doing so does not

increase other risks, remove an error-prone task by (re)design of system, procedure or process.

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 30

Mistakes(capacity overflow)

Slips & Lapses

Mistakes(incorrect solutions)

Exceptionalviolations

Routineviolations

Optimizingviolations

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 31

Slips & Lapses

Mistakes(incorrect solutions)

Routineviolations

Optimizingviolations

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 32

Slips & Lapses

Mistakes(incorrect solutions)

Routineviolations

Optimizingviolations

• Error Tolerance• Error Reduction• Error Detection

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 33

Mistakes(incorrect solutions)

Routineviolations

Optimizingviolations

Key issues:• Situation Recognition and Diagnosis• Decision Making

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 34

Violation Management

Routineviolations

Optimizingviolations

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 35

Optimizingviolations

The “Lethal Cocktail”

Expectation that rules will have to be bent to get the job done

Feeling of Powerfulness: above-average people need not follow all procedures

Opportunities to “short cut”Inadequate Planning, forcing

people to improviseRoutine

violations

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 36

Optimizingviolations

Remove the need to ViolateAdequate planning

Capability to adapt to new demands

Open communication

Safety Culture

Routineviolations

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 37

Can’t we hold people responsible for their mistakes and violations?

Real safety enhancement usually comes from systemic solutions

Not from actions at the individual level

Situation where a person really has to be removed from operation is very rare

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 38

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 39

OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 40

Look BEHIND the error or violation

What type of error?

Find solutions

Real, systemic